Introduction
Historically, treatment of tubal factor infertility was limited to surgical restoration of normal pelvic architecture and the opening of obstructed fallopian tubes. Due to the high pregnancy rates achieved with in vitro fertilization (IVF), the role of surgical repair for tubal pathology has decreased. IVF bypasses tubal disease by direct retrieval of oocytes and uterine replacement of embryos. Surgical treatment of tubal disease is progressively less successful with worsening tubal pathology, whereas success rates with IVF are unaffected by the extent of tubal damage, except in cases of hydrosalpinges. In addition to lower pregnancy rates, surgical treatment is associated with an average of a 1.6 year delay to conception. Ectopic pregnancies are also more common after surgical treatment (5–20%) in comparison to IVF (1%). The biggest disadvantage to IVF is the significant cost to the patient.
Although the success of surgical repair for extensive tubal damage may be limited, there is a role for tubal repair in the case of minimal-to-moderate tubal damage. Tubal surgery can be justified with moderate-to-severe tubal disease when this is the only viable treatment option available to the patient. The prognosis for fertility after tubal reconstruction depends on the severity of the pre-existing disease. The probability of an intrauterine pregnancy following tuboplasty can range from 3% to 77%, depending on the degree of tubal damage.
The modern microsurgical approach to pelvic reconstruction has nearly doubled pregnancy rates when compared with conventional macrosurgical techniques. Magnification permits pinpoint application of energy sources so that minimal tissue is damaged. Presently, pregnancy rates for laparoscopy appear comparable to rates following laparotomy. However, operative laparoscopy is associated with a faster recovery, lower incidence of postoperative ileus, decreased postoperative pain, and a shorter hospital stay. Additionally, in the closed laparoscopic environment, drying of tissues is minimized and bleeding is reduced secondary to tamponade from the pneumoperitoneum, leading to decreased postoperative adhesion formation.
Prior to surgery, a thorough evaluation including history, physical examination, pelvic ultrasound, semen analysis, assessment of ovulation, and hysterosalpingogram should be performed as well as a review of any prior operative reports. The patient should be counseled extensively about the possible surgical findings and treatment options, as well as the risks of ectopic pregnancy and surgical treatment failure. Surgical treatment for tubal factor infertility can be categorized as adhesiolysis, fimbrioplasty, neosalpingostomy, removal of hydrosalpinx, proximal tubal cannulation, uterotubal junction implantation and tubal reanastomosis.
For those patients with periadnexal adhesions, pregnancy rates can be substantially reduced as pelvic adhesions may impair oocyte pick-up between the ovary and fimbria. Adhesiolysis involves removing peritubal and adnexal adhesions. Tulandi et al. calculated cumulative pregnancy rates among infertile patients with adnexal adhesions. After adhesiolysis, these rates were 32% and 45% at 12 and 24 months respectively, but only 11% and 16% in the same time periods in patients who did not undergo adhesiolysis. Although the adhesiolysis was performed by laparotomy in these patients, similar results can be expected via laparoscopy.
Microsurgical techniques minimize the risk of postoperative adhesion formation. Other recommended ways to reduce postoperative adhesion formation include tissue irrigation, delicate handling of tissue, minimal suturing, minimal blood loss, and the use of prophylactic antibiotics. Intraoperatively, physical barriers have been utilized in order to minimize adhesion formation. Both oxidized regenerated cellulose and hyaluronic acid sheets have been shown to be effective in decreasing postoperative adhesion formation.
Fimbrioplasty refers to repair of the fimbria at the distal end of the fallopian tube. Fimbrial phimosis, damage or loss of the fimbria, can lead to partial obstruction of the fallopian tube. Often, adhesive bands are found surrounding and occluding the distal end of the tube. Surgical procedures can release agglutinized fimbria, lyze adhesive bands or broaden a phimotic fimbrial opening. Repair can be accomplished by either direct release of occlusive bands or by gently opening a forcep after it has been inserted into the end of the tube to release minor agglutination and stretch the opening. Pregnancy rates for patients undergoing fimbrioplasty are excellent. Donnez et al. reported a 60% intrauterine pregnancy rate with a 2% ectopic rate after fimbrioplasty. A similar study found a 51% pregnancy rate and 37% livebirth rate after laparoscopic fimbrioplasty in infertile women.
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